On Tuesday, Nov. 29, during RSNA22, the annual meeting of the Radiological Society of North America being held at Chicago’s McCormick Place Convention Center, a robust discussion about the future of the Medicare program and its implications for radiologists and others in healthcare, took place during a session entitled “Medicare and U.S. Healthcare Policy: A National Conversation.”
Amanda Starc, Ph.D., an associate professor of strategy in the Kellogg School of Management at Northwestern University (Evanston, Ill.) and a faculty research fellow at the National Bureau of Economic Research (NBER), moderated the discussion. She was joined by Mark McClellan, M.D., Ph.D., the Robert J. Margolis Professor of Business, Medicine, and Policy, and founding director of the Duke-Margolis Center for Health Policy at Duke University, and a former Administrator of the Centers for Medicare and Medicaid Services (CMS), and by Kavita Patel, M.D., a nonresident fellow at the Brookings Institution and an advisor to the Bipartisan Policy Center and a member of the Department of Health and Human Services’ Physician-Focused Payment Model Technical Advisory Committee. She had served as a senior healthcare policy development adviser to Valerie Jarrett in the Obama administration.
Drs. McClellan and Patel shared widely their perspectives based both on having spent time in policy development and as practicing physicians (and Dr. Patel continues to practice clinically in the present).
After a broad discussion of the overall landscape around healthcare reform, payment changes, and the evolution of alternative payment models (APMs) and accountable care organizations (ACOs), the question came up as to where radiologists and radiology fit into the conversation. “It is important for radiology to be a part of all of this, including population health-based models and ACOs,” Patel said. “How do we get more women to get mammograms? How do we ensure follow-ups to diagnostic imaging procedures? I don’t think we see enough of radiology’s presence at the table” when it comes to conversations around how to improve patients’ access to specialist-delivered medicine, she said.
Further, McClellan said, “Where this is all headed is towards the best outcomes at the lowest cost. If you stick with the fee-for-service system, you’ll just see continued reductions in payment and potentially service. The right question is, what should the future model of radiology practice look like, with better technology and better outcomes? Walking the exhibit floor,” he said, “several thing are clear: there will be more imaging, not less, at lower costs. It’s going to be less costly. AI [artificial intelligence] is already contributing to that by reducing the cost of quality scans, but also in the support needed to do procedures effectively. And three, there will be the need to target the right imaging supports and guidance around particular patients.”
Importantly, McClellan went on to say, “There are more things we can do, and more times in which we can do it. Costs will get lower, and AI will help us in terms of support. And some of these new imaging technologies will help us providing diagnostic imaging services to communities at lower cost. At CMS, the first version of this was ACOs that shifted some fee-for-service payment away from paying for specific services and towards the person level. And those were focused on primary care above all else. That was necessary” as an early step for the healthcare system, he emphasized. “A lot of preventive services, lots of opportunities for value creation there. On the specialty side, the bundled payments have been major innovations, around major surgery. The BCPI [Bundled Payments for Care Improvement] Initiative has been the biggest initiative under Medicare so far” to fully encompass specialist participation, he said. Even so, he added, “That bundle focuses on inpatient admission through a 30-to-60-day period after that. It was more about post-acute management. What Medicare is looking at as a big opportunity going forward is makings sure we’re supporting not just primary care but specialists in heading off procedures that aren’t necessary.”
Indeed, McClellan went on to say, “Per joint replacement, that means making sure to consult effectively, and later to do a better management with pain management and with post-operative care management. Shared decision-making with patients. Or e-consults, in terms of radiologists. Making sure the right tests are ordered for the right patient. And investing in not just interpreting scans the right way, but leading in making sure the right, best, and most efficient imaging procedures are used. So a move from relying on payments for performing traditional services, which are admittedly going on, but instead, paying for longitudinal practice, and giving specialists a more comprehensive role. And I think for radiologists, it will be figuring out their new role, and how we get there, in terms of reimbursement. It’s unlikely that CMS will carve out new payment models for radiologists or aspects of radiology. Instead, they’ll look at, for example, bringing radiologists into long-term support for patients, particularly for cancer patients who are surviving cancer. So could there be bundled payments for cancer survive care management?”
Starc then introduced the topic of the Medicare Advantage program, and what innovations might take place inside MA that might point the way to the future in the next few years. Given that half of Medicare beneficiaries are already in MA, she asked Dr. Patel how she viewed the potential for innovation inside that program.
“I like to say, when we get into more complex discussions,” Patel said, “that I try to go back to the basics, and when you think about any of our own lives—we have very busy lives, we’re educated here; and it’s still challenging. Add to that, people who don’t have our level of education, resource, or means, who are churning from one plan to another. These are the problems of a beneficiary, who might not realize they’ve gone years without follow-up or care management. And Mark and I have both lived through MA being idealized, then demonized, then, ‘we’ll live with it.’ What I’ve appreciated is… My father is on a Medicare management program, he has a nurse practitioner who will come into his home every month; he’s exactly that patient who otherwise won’t do the follow-up.”
Importantly, Patel went on, “Medicare offers the opportunity to intrinsically experiment with care models; that’s exactly what’s produced innovative care models that organizations like Oak Street and ChenMed have pursued. I just have to add into this that just on a prior note, per MA and value-based, we’ve been focused here on the reimbursement/financing aspect; but per radiology, we need to ameliorate the bureaucratic burden around prior authorization, the ability to work with utilization. So often, those in APMs have figured out how to strike a balance and make it somewhat easier to practice as physicians, while at the same time achieving better care at lower costs. MA offers opportunity to improve outcomes and lower costs.”
“Is that a good thing?” Starc asked McClellan. “Should we entrust your successor at CMS to try out new models?” she asked, referring to current CMS Administrator Chiquita Brooks-LaSure.
“The Medicare Advantage program has grown steadily over both Republican and Democratic administrations,” McClellan noted. “In MA, there are more incentives than in fee-for-service, to document what conditions a patient has; and that’s a fixable problem. But plans also get paid more for increasing cancer screening rates, reducing hospitalizations, achieve higher beneficiary satisfaction. There is flexibility. MA is the leading adopter of APMs across all programs, across the country. And that will continue to grow. And for those concerned about government-run healthcare,” he added, “Medicaid is already 90 percent in managed care plans. So the question is, can we bring the right policy to these managed care programs, so they get better alignment with patients? And on the Medicaid side, a lot of the work is around, how do we get plans to become more accountable for outcomes? That’s where the future is headed: more government oversight of Medicare and Medicaid plans. The question is whether we can do it right.”
Starc then asked Patel whether she sees the Center for Medicare and Medicaid Innovation (CMMI) potentially encouraging the development of AI algorithms.
“I don’t think that CMS is going to be focused on investing in technology into clinical care,” Patel said. And I don’t think that’s what we want as clinicians; we want them to increase flexibility. And per AI, in terms of radiology, this is not a panacea, nor a silver bullet that will disrupt and change every aspect of radiology as a profession. It is one of many tools that could facilitate greater flexibility and potentially, higher throughput, since so many of us, including myself, are still being paid according to RVUs.”
She went on to say that, “In terms of the FDA [Food and Drug Administration], bringing these new technologies in and to make sure they’re more effective, that’s where the two agencies meet. You want innovative technologies to be adopted. We are seeing a lot more AI modalities that are coming through the FDA and then being adopted. And CMS will have to deal with the fact at some point that some very special type of AI could emerge. But right now, there’s just an incentive and interest in adopting AI because of gaps in care, improving quality, and closing gaps in care. AI is only as good as how it’s developed. Meanwhile, in ten years we’ll have a conversation less about the reimbursement but rather about how robotics in surgery, for example, has become a fixture and a mainstay. That, I think, is where we’ll see more development.”